Changing policy and practice: Making sense of national guidelines for osteoarthritis

Abstract

Understanding uptake of complex interventions is an increasingly prominent area of research. The interplay of macro (such as changing health policy), meso (re-organisation of professional work) and micro (rationalisation of clinical care) factors upon uptake of complex interventions has rarely been explored. This study focuses on how English General Practitioners and practice nurses make sense of a complex intervention for the management of osteoarthritis, using the macro-meso-micro contextual approach and Normalisation Process Theory (NPT), specifically the construct of coherence. It is embedded in a cluster RCT comprising four control practices and four intervention practices. In order to study sense-making by professionals introduction and planning meetings (N = 14) between researchers and the practices were observed. Three group interviews were carried out with 10 GPs and 5 practice nurses after they had received training in the intervention. Transcripts were thematically analysed before comparison with NPT constructs. We found that: first, most GPs and all nurses distinguished the intervention from current ways of working. Second, from the introduction meeting to the completion of the training the purpose of the intervention increased in clarity. Third, GPs varied in their understanding of their remit, while the practice nurses felt that the intervention builds on their holistic care approach. Fourth, the intervention was valued by practice nurses as it strengthened their expert status. GPs saw its value as work substitution, but felt that a positive conceptualisation of OA enhanced the consultation. When introducing new interventions in healthcare settings the interaction between macro, meso and micro factors, as well as the means of engaging new clinical practices and their sense-making by clinicians needs to be considered.

Factors influencing the implementation of evidence‐based guidelines for osteoarthritis in primary care: A systematic review and thematic synthesis

“…The searches identified 1612 titles, leaving 1175 after de‐duplication. Four articles that were eligible for inclusion in the review (Cuperus et al, ; Morden et al, ; Morden, Jinks, Ong, Porcheret, & Dziedzic, ; Ong et al, ). The review process is demonstrated in Figure .…”

A nurse-led clinic for patients consulting with osteoarthritis in general practice: development and impact of training in a cluster randomised controlled trial

“…This seems to be reflected in the clinical management, as it appears that the nurses focused on the core treatments of information provision, encouraging weight management and physical activity. This finding was also reflected in the post intervention group interview with the nurses, a component of the qualitative work within the MOSAICS study [43, 44]. In a group interview the nurses described how they felt more confident dealing with patients who consulted with OA and were able to modify their relationship with OA patients, because they had the opportunity to play more of an active role in patient care [43].…”

“…In a group interview the nurses described how they felt more confident dealing with patients who consulted with OA and were able to modify their relationship with OA patients, because they had the opportunity to play more of an active role in patient care [43]. Ong et al [44] also reported that the nurses recognised that they had lacked skills and knowledge of OA previously, felt that the training had helped to up skill them in this regard, and left them feeling they could manage patients with OA better than previously, and boosted their professional standing. Despite the nurses being encouraged to use the OA guidebook as part of each consultation, its use dropped off considerably over the course of the four consultations This may be due to the nurses feeling more knowledgeable and confident as reflected in the findings from the group interview, clinical management and post-training questionnaire data, and therefore they felt less reliant on the use of the written information.…”

Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomised controlled trials

“…178 Factors relevant to participation in the MOSAICS studies To facilitate recruitment and operationalisation of complex interventions, the research team needed to pay attention to the existing clinical concerns, internal power dynamics and workloads within individual primary care organisations. Logistics and existing communication channels influenced how health-care professionals made sense of the study and organised their roles in relation to it.…”